Exploring the use of social network analysis methods in process improvement within healthcare organizations: a scoping review

BACKGROUND

Communication breakdowns among healthcare providers have been identified as a significant cause of preventable adverse events, including harm to patients. A large proportion of studies investigating communication in healthcare organizations lack the necessary understanding of social networks to make meaningful improvements. Process Improvement in healthcare (systematic approach of identifying, analyzing, and enhancing workflows) is needed to improve quality and patient safety. This review aimed to characterize the use of SNA methods in Process Improvement within healthcare organizations.

METHODS

Relevant studies were identified through a systematic search of seven databases from inception - October 2022. No limits were placed on study design or language. The reviewers independently charted data from eligible full-text studies using a standardized data abstraction form and resolved discrepancies by consensus. The abstracted information was synthesized quantitatively and narratively.

RESULTS

Upon full-text review, 38 unique articles were included. Most studies were published between 2015 and 2021 (26, 68%). Studies focused primarily on physicians and nursing staff. The majority of identified studies were descriptive and cross-sectional, with 5 studies using longitudinal experimental study designs. SNA studies in healthcare focusing on process improvement spanned three themes: Organizational structure (e.g., hierarchical structures, professional boundaries, geographical dispersion, technology limitations that impact communication and collaboration), team performance (e.g., communication patterns and information flow among providers., and influential actors (e.g., key individuals or roles within healthcare teams who serve as central connectors or influencers in communication and decision-making processes).

CONCLUSIONS

SNA methods can characterize Process Improvement through mapping, quantifying, and visualizing social relations, revealing inefficiencies, which can then be targeted to develop interventions to enhance communication, foster collaboration, and improve patient safety.

Surgical Safety Does Not Happen By Accident: Learning From Perioperative Near Miss Case Studies

Adverse surgical events cause negative patient health outcomes and harm that can often overshadow the safe and effective patient care provided daily by nurses as members of interprofessional healthcare teams. Near misses occur far more frequently than adverse events and are less visible to nurse leaders because patient harm is avoided due to chance, prevention, or mitigation. However, near misses have comparable root causes to adverse events and exhibit the same underlying patterns of failure. Reviewing near misses provides nurses with learning opportunities to identify patient care weaknesses and build appropriate solutions to enhance care. As the operating room is one of the most complex work settings in healthcare, identifying potential weaknesses or sources for errors is vital to reduce healthcare-associated risks for patients and staff. The purpose of this manuscript is to educate, inform, and stimulate critical thinking by discussing perioperative near miss case studies and the underlying factors that lead to errors. Our authors discuss 15 near miss case studies occurring across the perioperative patient experience of care and discuss barriers to near miss reporting. Nurse leaders can use our case studies to stimulate discussion among perioperative and perianesthesia nurses in their hospitals to inform comprehensive risk reduction programs.

Surgical Team Structure: How Familiarity and Team Size Influence Communication Effectiveness in Military Surgical Teams

INTRODUCTION

Preventable patient harm has persisted in health care despite recent advances to reduce errors. There is increasing recognition that non-technical skills, including communication and relationships, greatly impact interprofessional team performance and health care quality. Team familiarity and size are critical structural components that potentially influence information flow, communication, and efficiency.

METHODS

In this exploratory, prospective, cross-sectional study, we investigated the key structural components of surgical teams and identified how surgical team structure shapes communication effectiveness. Using total population sampling, we recruited surgical clinicians who provide direct patient care at a 138-bed military medical center. We used statistical modeling to characterize the relationship between communication effectiveness and five predictors: team familiarity, team size, surgical complexity, and the presence of surgical residents and student anesthesia professionals.

RESULTS

We surveyed 137 surgical teams composed of 149 multidisciplinary clinicians for an 82% response rate. The mean communication effectiveness score was 4.61 (SD = 0.30), the average team size was 4.53 (SD = 0.69) persons, and the average surgical complexity was 10.85 relative value units (SD = 6.86). The surgical teams exhibited high variability in familiarity, with teams co-performing 26% (SD = 0.16) of each other's surgeries. We found for every unit increase in team familiarity, communication effectiveness increased by 0.36 (P ≤ .05), whereas adding one additional member to the surgical team decreased communication effectiveness by 0.1 (P ≤ .05). Surgical complexity and the influence of residents and students were not associated with communication effectiveness.

CONCLUSIONS

For military surgical teams, greater familiarity and smaller team sizes were associated with small improvements in communication effectiveness. Military leaders can likely enhance team communication by engaging in a thoughtful and concerted program to foster cohesion by building familiarity and optimizing team size to meet task and cognitive demands. We suggest leaders develop bundled approaches to improve communication by integrating team familiarity and team size optimization into current evidence-based initiatives to enhance performance.

Team Consistency in Reducing Operative Time in Head and Neck Surgery with Microvascular Free Flap Reconstruction

OBJECTIVE(S)

To evaluate the impact of consistent surgical teams on procedure duration in head and neck free tissue transfer, and to evaluate the length of stay and readmission rates with consistent teams.

METHODS

A retrospective chart review of head and neck microvascular reconstruction by a single surgeon between August 2017 and November 2021 was performed. Procedure duration, wound complications, length of stay, and 30-day readmissions were analyzed. One circulating nurse (CN) and surgical technologist (ST) were considered "consistent" due to their prior work with the primary surgeon. All others were considered "ad hoc." Teams were "Consistent CN + ST," "Consistent ST," "Consistent CN," or "Ad hoc." Procedure duration between groups was compared via analysis of variance. Multivariate linear regression was performed to predict procedure duration.

RESULTS

A total of 135 patients were included. Age, sex, and American Society of Anesthesiologists status did not significantly differ across groups (p = 0.963; p = 0.467; p = 0.908, respectively). The mean procedure duration was 339.3 min and differed significantly across all groups (p = 0.006, Cohen d = 0.32). Compared to the Ad hoc group, consistent teams demonstrated significant reductions in mean procedure duration (Consistent CN + ST: 58.4 min, p = 0.001, Cohen d = 0.67; Consistent ST: 51.6 min, p = 0.013, Cohen d = 0.61; Consistent CN: 44.5 min, p = 0.031, Cohen d = 0.52). Controlling for other factors, the ad hoc team predicted increased procedure duration on multivariate analysis ( β 57.38, 19.92-94.85, p < 0.003). Wound complications, length of stay, and readmission rates did not differ significantly across groups (p = 0.940; p = 0.174; p = 0.935, respectively).

CONCLUSION

Consistent CN and ST improve operative efficiency in head and neck-free tissue transfer. Future studies may evaluate the impact of team consistency on complications, physician burnout, and health systems costs.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2154-2159, 2023.

Exploring the competencies of operating room nurses in mobile surgical teams based on the Onion Model: a qualitative study

BACKGROUND

With the frequent occurrence of public health emergencies, conflicts and natural disasters around the world, mobile surgical teams are becoming more crucial. The competency of the operating room (OR) nurse has a substantial impact on the effectiveness and quality of the surgical team's treatment, still there is limited knowledge about OR nurse competencies in mobile surgical teams. This study aimed to explore the competencies of OR nurses in mobile surgical teams based on the Onion Model.

METHODS

We conducted a qualitative descriptive study of participants from 10 mobile surgical teams in 2022. Twenty-one surgical team members were interviewed, including 15 OR nurses, four surgeons, and two anesthesiologists. Data were collected through semi-structured interviews. The data were analyzed using Mayring's content analysis.

RESULTS

Twenty-eight competencies were found in the data analysis, which were grouped into four major domains using the Onion Model. From the outer layer to the inner layer were knowledge and skills, professional abilities, professional quality, and personal traits. The qualitative data revealed several novel competencies, including triage knowledge, self and mutual medical aid, outdoor survival skills, and sense of discipline.

CONCLUSIONS

The application of the Onion Model promotes the understanding of competency and strengthens the theoretical foundations of this study. New competencies can enrich the content of the competencies of OR nurses. The results of this study can be used for clinical recruitment, evaluation and training of OR nurses in mobile surgical teams. This study encourages further research to develop competency assessment tools and training programs for OR nurses.

Factor Structure and Construct Validity of a Hospital Survey on Patient Safety Culture Using Exploratory Factor Analysis

OBJECTIVE

Nurses' voluntary reporting of adverse events and errors is critical for improving patient safety. The operationalization and application of the concept, patient safety culture, warrant further study. The objectives are to explore the underlying factor structure, the correlational relationship, between items of the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture and examine its construct validity.

METHODS

Exploratory factor analysis was conducted using secondary data from the instrument's database. Using pattern matching, factors obtained through exploratory factor analysis were compared with the 6-component Patient Safety Culture Theoretical Framework: degree of psychological safety, degree of organizational culture, quality of culture of safety, degree of high reliability organization, degree of deference to expertise, and extent of resilience.

RESULTS

6 exploratory factors, explaining 51% of the total variance, were communication lead/speak out/resilience, organizational culture and culture of safety-environment, psychological safety-security/protection, psychological safety-support/trust, patient safety, communication, and reporting for patient safety. All factors had moderate to very strong associations (range, 0.354-0.924). Overall, construct validity was good, but few exploratory factors matched the theoretical components of degree of deference to expertise and extent of resilience.

CONCLUSIONS

Factors essential to creating an environment of transparent, voluntary error reporting are proposed. Items are needed, specifically focusing on deference to expertise, the ability of the person with the most experience to speak up and lead, despite hierarchy or traditional roles, and resilience, which is coping and moving forward after adversity or mistakes. With future studies, a supplemental survey with these items may be proposed.

Associations of Surgical Team Communication With the Layout of Physical Space: A Network Analysis of the Operating Room in a Military Medical Center

AIM

To examine how the spatial topology of the operating room (OR) within the medical center impacts surgical team communication.

BACKGROUND

Understanding the complex association between surgical team communication and the OR's spatial network location is critical to patient safety. Effective surgical communication is associated with fewer adverse events and medical errors.

METHODS

We employed a cross-sectional, quantitative, case study, and network-centric study design. We studied the population of 204 clinicians in a large military medical center (36 perioperative nurses, 34 surgical technicians, 62 anesthesia providers, and 72 surgeons), focusing on surgical teams with cases completed within duty hours. Data were collected from December 2020 to June 2021 using an electronic survey. Spatial network analysis was done using electronic floor plans. Statistical analysis was done with descriptive statistics and linear regressions. The outcomes were general and task-specific communication, and team-level variables were aggregated from scores for all team members. Spatial effects were assessed with network centrality (degree, Laplacian, and betweenness).

RESULTS

The individual-level survey response rate was 77% (157 of 204). Data were collected on 137 surgical teams. On a 5-point scale, general and task-specific communication ranged from 3.4 to 5.0 and 3.5 to 5.0, respectively (for both, median = 4.7). Team size ranged from 4 to 6 individuals (median = 4). Surgical suites with higher network centralities were associated with significantly lower communication scores.

CONCLUSIONS

The OR's spatial network location has important impacts on surgical team communication. Our findings have design and workflow implications for ORs and even surgical care in combat zones.

Differences in Perioperative Nurse Job Satisfaction by Specialty Certification Status

PURPOSE

To describe differences in perioperative RN job satisfaction by specialty certification status.

DESIGN

A retrospective, exploratory, cross-sectional design.

METHODS

We conducted a secondary analysis of annual data from the National Database of Nursing Quality Indicators (NDNQI) RN Survey with 12 Job Satisfaction Scales. The sample consisted of 776 perioperative units in 206 hospitals with 13,061 study participants. We used multilevel mixed modeling to examine differences in job satisfaction for nurses holding CAPA (Certified Ambulatory Perianesthesia Nurse), CPAN (Certified Post Anesthesia Nurse), CNOR (certification for perioperative registered nurses), CRNFA (Certified RN First Assistant), other specialty certification, and not specialty certified.

FINDINGS

Twelve percent of RN participants held a perioperative nursing certification (CAPA, CPAN, CNOR, CRNFA), 15% held other nursing specialty certifications, and 73% were not certified. Regardless of certification status, nurses were the most satisfied with nurse-nurse interactions and task. They were the least satisfied with nursing administration, decision-making, and pay. CNOR certified nurses reported the lowest levels of job satisfaction in the study. CAPA and CPAN certified nurses reported higher job satisfaction than their noncertified colleagues on multiple job satisfaction scales (ie, CAPA 10 of 12; CPAN 5 of 12). CNOR certified nurses did not report meaningful differences in job satisfaction from non-certified nurses.

CONCLUSIONS

As job satisfaction impacts retention, productivity, and patient care quality, our findings have important implications for hospital leaders, nurses, and health care consumers. Based on our findings, we identified nursing professional development as a potential gap in job satisfaction that leaders can target for improvement. Our findings suggest that higher specialty nursing certification rates in perianesthesia nurses may potentially improve job satisfaction and retention of nurses.

Fire in the Operating Room: Surgical Case Report From a Forced-Air Warming Device Equipment Fire

Surgical fires are critical life-threatening events that can result in patient morbidity and mortality. This case report describes an equipment fire originating from a forced-air warming device occurring during a shoulder arthroscopy operation and discusses how the surgical team responded to mitigate risks to the patient and staff. Rapid response by the anesthesia professional and the surgical team helped prevent the fire from negatively impacting patient and staff safety. The patient was discharged from the hospital without any complications. We recommend that surgical teams engage in a coordinated and continual cycle of fire prevention, including enhanced education and interprofessional team training.

Adverse Event Reporting Priorities: An Integrative Review

OBJECTIVES

Adverse events remain the third leading cause of death in hospitals today, after heart disease and cancer. However, adverse events remain underreported. The purpose of this integrative review is to synthesize adverse event reporting priorities in acute care hospitals from quantitative, qualitative, and mixed-methods research articles.

METHODS

A comprehensive review of articles was conducted using nursing, medicine, and communication databases between January 1, 1999, and May 3, 2021. The literature was described using standard reporting criteria.

RESULTS

Twenty-nine studies met the eligibility criteria. Four key priorities emerged: understanding and reducing barriers, improving perceptions of adverse event reporting within healthcare hierarchies, improving organizational culture, and improving outcomes measurement.

CONCLUSIONS

A paucity of literature on adverse event reporting within acute care hospital settings was found. Perceptions of fear of blaming and retaliation, lack of feedback, and comfort level of challenging someone more powerful present the greatest barriers to adverse event reporting. Based on qualitative studies, obtaining trusting relationships and sustaining that trust, especially in hierarchical healthcare systems, are difficult to achieve. Given that patient safety training is a common strategy clinically to improve organizational culture, only 4 published articles examined its effectiveness. Further research in acute care hospitals is needed on all 4 key priorities. The findings of this review may ultimately be used by clinicians and researchers to reduce adverse events and develop future research questions.

Relational Coordination Among Military and Civilian Nurses and Physicians in an Army Hospital: Do Demographic Characteristics and Professional Roles Matter?

OBJECTIVE

The aim of this study was to explore whether demographic characteristics and professional roles are associated with relational coordination (RC) among nurses and physicians.

BACKGROUND

The increased race, age, and gender diversity in the nursing and medical workforce raises questions regarding how well nurses and physicians communicate and interact. Relational coordination is a unique framework to enhance teamwork and care coordination among healthcare professionals.

METHODS

An exploratory cross-sectional study was conducted in a military hospital. The study variables were examined using multiple regression.

RESULTS

Two-hundred eighty-nine participants completed the survey. Professional role, race, age, gender, and experience were not associated with RC. Rank and education were significantly associated with RC. Enlisted service members reported higher RC between roles, and participants with graduate degrees reported lower RC within roles.

CONCLUSION

Hospital leaders can implement RC to foster inclusivity and teamwork among healthcare professionals despite demographic characteristics and professional roles.

Operation Allies Refuge and Operation Allies Welcome: Military Perioperative and Perianesthesia Nursing Support to the Afghan Evacuation Mission

Nursing has a long and celebrated history of providing life-saving care during crises and periods of great need. Following the government collapse in Afghanistan and the withdrawal of US troops, a severe humanitarian and human rights crisis emerged. The US military participated in one of the largest and most complex humanitarian missions in history to aid Afghan relief efforts. US and coalition forces evacuated more than 130,000 people in the chaotic Allied airlift from the Kabul Airport. The overarching missions, Operation Allies Refuge and Operation Allies Welcome, provided humanitarian support to at-risk Afghan nationals who contributed to the Global War on Terrorism efforts, as well as US citizens living in Afghanistan. Landstuhl Regional Medical Center (LRMC), an overseas military treatment facility located in Germany, supported the healthcare needs of Afghan evacuees and injured US service members during the humanitarian crisis. LRMC clinicians provided emergent, urgent, and specialty care while advocating for evacuee health, wellness, and living conditions. Perioperative and perianesthesia nurses were essential to the humanitarian response, as many evacuees and injured US service members arrived in Germany requiring immediate surgical interventions. In this article, we describe the vital contributions of military perioperative and perianesthesia nurses to the Operation Allies Refuge and Operation Allies Welcome missions, and share our experiences providing humanitarian relief. Military and civilian healthcare planners can learn from our humanitarian relief contributions, experiences, and lessons to strategically prepare their health systems to respond to future crises.

Fragmentation of practice: The adverse effect of surgeons moving around

BACKGROUND

Whether surgical team familiarity is associated with improved postoperative outcomes remains unknown. We sought to characterize the impact of fragmented surgical practice on the likelihood that a patient would experience a textbook outcome, which is a validated patient-centric composite outcome representing an "ideal" postoperative outcome.

METHOD

Medicare beneficiaries aged 65 and older who underwent elective inpatient abdominal aortic aneurysm repair, coronary artery bypass graft, cholecystectomy, colectomy, or lung resection were identified. Rate of fragmented practice was calculated based on the total number of surgical procedures of interest performed over the study period (2013-2017) divided by the number of different hospitals in which the surgeon operated. Surgeons were categorized into "low," "average," "above average," or "high" rate of fragmented practice categories using an unsupervised machine learning technique known k-medians cluster analysis.

RESULTS

Among 546,422 Medicare beneficiaries who underwent an elective surgical procedure of interest (coronary artery bypass graft: n = 156,384, 28.6%; lung resection: n = 83,164, 15.2%; abdominal aortic aneurysm: n = 112,578, 20.6%; cholecystectomy: n = 42,955, 7.9%; colectomy: n = 151,341, 27.7%), median patient age was 74 years (interquartile range: 69-80), and most patients were male (n = 319,153, 58.4%). Machine learning identified 3 cutoffs to categorize rate of fragmented practice: 2.8%, 5.6%, and 10.6%. Overall, the majority of surgical procedures were performed by surgeons with a low rate of fragmented practice (n = 382,504, 70.0%); other surgical procedures were performed by surgeons with average (n = 109,141, 20.0%), above average (n = 44,249, 8.1%), or high (n = 10,528, 1.9%) rate of fragmented practice. On multivariable analyses, after controlling for patient demographics, individual surgeon volume, procedure type, and a random effect for hospital, patients who underwent a surgical procedure by a high versus low rate of fragmented practice surgeon had lower odds to achieve a postoperative textbook outcome (odds ratio 0.71, 95% confidence interval 0.77-0.84). Patients who underwent a procedure by a high rate of fragmented practice surgeon also had increased odds of a perioperative complication (odds ratio 1.30, 95% confidence interval: 1.23-1.37), extended length of stay (odds ratio 1.17, 95% confidence interval: 1.11-1.24), 90-day readmission (odds ratio 1.17, 95% confidence interval: 1.11-1.23), and 90-day mortality (odds ratio 1.29, 95% confidence interval: 1.17-1.42) (all P < .05).

CONCLUSION

Patients undergoing a surgical procedure by a surgeon with a high rate of fragmented practice had lower odds of achieving an optimal postoperative textbook outcome. Surgical team familiarity, measured by a surgeon rate of fragmented practice, may represent a modifiable mechanism to improve surgical outcomes.

Military Surgical Team Performance: The Impact of Familiarity, Team Size, and Nurse Anesthesia Students

PURPOSE

To examine the key factors impacting surgical team performance in a military medical center.

DESIGN

A retrospective, exploratory, cross-sectional design.

METHODS

We reviewed 751 orthopedic surgical cases to determine the association of surgical team familiarity, surgical complexity, team size, and the presence of student registered nurse anesthetists (SRNAs) with the surgical performance measures of total operative time, turnover time, and on-time surgical start.

FINDINGS

We found increases in surgical team familiarity significantly reduced turnover time by 7.84% (1-0.9216 = 0.0784; P = .0260) after controlling for surgical complexity and the presence of an SRNA on the team. Familiarity did not significantly impact total operative time or the odds of a first case on-time start. With a significant interaction of surgical complexity and team size on total operative time, the surgical complexity marginal effect (at the mean of team size) showed that a one-point increase prolonged total operative time by 6.89% (P < .0001), after controlling for team familiarity and an SRNA. The team size marginal effect (at the mean of surgical complexity) showed that adding one member to the surgical team prolonged total operative time by 6.45% (P < .0001), after controlling for team familiarity and an SRNA. Higher surgical complexity not only increased turnover time by 1.46% (P = .0265) while holding surgical complexity and an SRNA presence constant, but also reduced the likelihood of an on-time surgical start by 0.9359 (P = .0060). Larger teams decreased the odds of an on-time start by 0.7750 (P = .0363). We found that SRNAs potentially offer efficiency benefits, as their presence on a surgical team was associated with a 0.82% (1-0.9185 = 0.0815; P = .0007) decrease in total operative time, and a 21.01% (1-0.7899=0.2101; P = .0002) reduction in expected turnover time, after adjusting for confounding variables.

CONCLUSIONS

Surgical efficiency is a modifiable function of surgical teams. Although we suggest additional research, surgical leaders can potentially improve team performance by improving familiarity and forming small and cohesive surgical teams. As OR inefficiencies degrade the financial vitality of healthcare systems, surgical leaders should engage in a multifaceted program to improve efficiency by building familiarity and optimizing team size.

Surgical Team Familiarity: An Integrative Review

The dynamic nature of perioperative care often brings unfamiliar clinicians together yet requires them to collectively provide complex health care in a challenging environment. In this review, we comprehensively evaluated evidence regarding surgical team familiarity and its relationship to surgical team performance. Using a comprehensive and iterative search strategy, we searched PubMed, Web of Science, PsycInfo, and EMBASE for surgical team familiarity manuscripts. We identified 598 manuscripts, 16 of which met our inclusion criteria. We found that surgical team familiarity is associated with improved performance for many metrics, including shorter total operative time, team member safety, decreased surgical errors and disruptions, reduced miscommunication, and fewer patient readmissions. Although additional research would be helpful, surgical managers should consider team familiarity and consistency in team membership when assigning staff members to surgical teams to optimize surgical care, decrease inefficiencies, and promote safe patient outcomes.

A Protocol to Examine Surgical Team Communication in a Large Military Medical Center

BACKGROUND

Preventable clinician communication errors are the most frequent root cause of surgical adverse events. Effective communication among surgical team members is an important overall indicator of clinical nursing excellence and is crucial to promote patient safety and reduce healthcare risk.

OBJECTIVE

The purpose of this publication is to describe our research protocol, which will comprehensively investigate surgical team communication and surgical team structure. There are two overall study objectives: (a) to characterize the network factors that influence perioperative clinician communication and (b) to identify how team structure shapes communication effectiveness. Specifically, we will study the association among clinician relationships, surgical team familiarity, surgical team size, and communication effectiveness.

METHODS

We will use an exploratory, prospective, cross-sectional, network-centric approach using social network analysis to determine how interdependent clinician relationships influence surgical communication patterns. Targeting an 80% response rate, we will use total population sampling to recruit all clinicians (nurses, surgeons, anesthetists, surgical technologists, students, residents) who directly provide surgical care in the operating room at a large military medical center. We will administer an electronic survey to surgical teams at the end of the surgical day to elicit clinician communication assessments and relational preferences. From the survey questions, we will develop six relational networks (interaction, close working relationship, socialization, advice seeking, advice giving, speaking up/voice) and three models that represent communication effectiveness for each participant and team. We will use various statistical methods to characterize the network factors that shape operating room clinician communication and identify how team structure shapes communication effectiveness.

RESULTS

This study will start enrolling participants in 2020.

DISCUSSION

We are among the first to comprehensively investigate operating room communication using social network analysis. The results of this study will provide valuable insight into nurse collaboration and communication in interprofessional teams, enable a thoughtful analysis of surgical staffing and perioperative team building, and inform future-targeted interventions to improve operating room communication weaknesses.

Social network analysis: Exploring connections to advance military nursing science

BACKGROUND

Military nurse scientists are embedded in service-affiliated branches (Army, Navy, Air Force) with different missions, but with the singular purpose of generating and disseminating research impacting the health and well-being of DoD beneficiaries.

PURPOSE

This project examines collaboration among TriService Nursing Research Program (TSNRP) members, seeking opportunities to strengthen, diversify, and expand research collaboration.

METHOD

Social network analysis (SNA) is the empirical inquiry of relations among social actors at different levels of analysis. An electronic SNA assessment and total enumerative sampling were used to explore current collaborations among PhD-prepared military nurse scientists (N = 136).

FINDINGS

The TSNRP collaboration network has a complex service-driven structure with high status actors whose advice, knowledge, or skills are sought by others, and who function as connectors or bridges across service branches.

DISCUSSION

For military scientists, SNA is instrumental in identifying influential individuals, visualizing opportunities for intraservice mentoring, designing responsive policy, and directing career opportunities for novice scientists.

Non-Technical Skills in Social Networks: The Spread of Safety Communication and Teamwork in a Warehouse

Safety at work should be considered as the result of the daily interaction of operators. The present research wants to analyze which factors are involved in the development of social networks about safety at work. We assumed that two relational non-technical skills, such as safety communication and safety team member support, affect the in-degree and out-degree bonds of workers in social networks. One hundred and eight workers of a warehouse were the participants of the research, in which they were asked to fill out a self-reported questionnaire. Multiple linear regression analysis was used to test the hypotheses. Results confirmed that safety communication and safety support skills play a role in determining the quantity and the quality of social bonds that workers can create at the workplace. To be specific, while safety communication was found to be associated with out-degree centrality (b = 0.24; p = 0.01), a nonsignificant relationship was found for in-degree centrality. In contrast, safety team member support was found to be associated with in-degree centrality (b = 0.28; p = 0.04). In other words, on the one hand, it was found that high levels of safety communication skills are associated with the tendency of workers to proactively search for colleagues with whom they can share information about safety. On the other hand, workers with high levels of safety support skills tend to be considered as reference points in terms of safety by colleagues, who are more prone to look for their help. Implications for both scientists and practitioners are discussed.

Interventions and measurements of highly reliable/resilient organization implementations: A literature review

Since the inception of High Reliability Theory in 1981, researchers and practitioners have theorized about the questions, "How do you know if you're an HRO, and how do you validate it?" Evidence now exists that organizations seeking high reliability and resilience have moved away from the theoretical phase, and into the application phase where organizations adopt the HRO hallmarks plus culture as operational targets and create interventions to effect change. The evidence of high reliability operations in organizations is key for validating that HRO is implementable and is also beneficial. After collecting over 1400 artifacts, we found 34 scholarly efforts published which purposefully targeted implementation measures toward achieving an HRO state and measured the outcomes. From that evidence, we concluded that three specific interventions have been used which were useful and generalizable to guide practitioners in moving toward an HRO state: process redesign, training, and organization redesign. We suggest that this evidence may assert that organizations which are not functioning as an HRO can be redesigned to do so.

A Five-Step Evidence-Based Practice Primer for Perioperative RNs

Perioperative nurses work in a complex health care setting and are well-positioned to mitigate unexpected events and promote optimal patient outcomes. Thus, perioperative nurses must adapt to rapid advances in technology, treatments, and scientific discoveries to maintain clinical competence and provide care that reflects current evidence. Evidence-based practice (EBP) is a standard of professional nursing performance and an expectation of professional nursing practice. Because EBP is foundational to health care quality and safety, perioperative nurses must understand the concepts of EBP and have the capacity to apply evidence to their clinical practice. However, some perioperative nurses struggle with EBP concepts and find it difficult to access, appraise, and apply evidence. In this article, we describe the five-step EBP process and provide valuable insights into EBP for perioperative RNs.

Right care: Improving timeliness and promoting preventive health in a lower socioeconomic reproductive health clinic

BACKGROUND

Missed prevention opportunities are a financial burden to the US health care system and result in excess consumption of resources, reduced quality of life, increased morbidity, and premature death.

LOCAL PROBLEM

High staff turnover and inefficient practices at a local health department caused long patient wait times and missed opportunities for preventive health care. The project aim was to improve timeliness through Right Care in a lower socioeconomic reproductive health clinic while decreasing patient cycle time by 10% in 90 days.

METHODS

We used four plan-do-study-act cycles incorporating tests of change that focused on team and patient engagement and two process changes. The interventions included a care coordination huddle, an infant feeding decision aid to better understand patient values, a sexual health screening tool to identify prevention opportunities, and a redesigned patient-centered discharge process to improve efficiency.

RESULTS

Over 90 days, the receipt of Right Care increased while patient cycle time decreased by 2.6%. The team improved function with a mean huddle effectiveness score increase from 2 to 4.4 (1-5 Likert scale). Intent to breastfeed increased by 49% (35%-52%), and identification of preventive care needs increased by 320% (15%-63%). Preventive care follow-up remained unchanged at 26% with the new discharge process, identifying weaknesses in the health department referral systems.

CONCLUSIONS

Standardized tools and processes improved primary prevention opportunities at a local health department while reducing patient cycle time. The tools improved documentation of intent to exclusively breastfeed, increased preventive care identification, and streamlined the discharge process; while demonstrating a systems-level gap for long-term follow-up.

COVID-19: Initial Perioperative and Perianesthesia Nursing Response in a Military Medical Center

Nurses have historically led efforts to improve the health of populations while simultaneously and unselfishly providing care during pivotal moments of national need. The COVID-19 pandemic has placed an unprecedented strain on the US health care system, including severe shortages of hospital beds, supplies, equipment, pharmaceuticals, and healthy frontline clinicians. Perioperative and perianesthesia leaders and clinicians have unique opportunities to provide patient care during the COVID-19 crisis. In this manuscript, we describe the initial changing roles and contributions of perioperative and perianesthesia registered nurses during the COVID-19 pandemic and share recent experiences from a military medical center. Perioperative and perianesthesia nurses are vital to the overall nursing viability of the health care system, as they possess the requisite knowledge and skills to provide expert clinical care in many hospital settings and meet the demands of a global pandemic.